an innovative and integrated model for learning the essentials...an innovative and integrated model...
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Critical Care in
Obstetrics:
An Innovative and Integrated Model for
Learning the Essentials
Diabetic Ketoacidosis in
Pregnancy-
Case Presentations Jeffrey C. Faig, M.D., FACOG, FACP
Clinical Professor, Department of Obstetrics & Gynecology
Stanford University
I have no conflicts of interest to disclose
Disclosure
DKA in Pregnancy- Case Presentation 1
29 yo G2P0101 with DM1 for 24 years had PPROM at 29
wks. She was hospitalized, managed expectantly with
antibiotics, and had good glycemic control on split/mixed
insulin. At 34 wks induced with Pitocin.
At 0810 glucose was 67 mg/dl. Plan was to start IV insulin
and glucose when blood glucose > 100 mg/dl.
Over the next 24 hrs her glucose ranged from 45-93 mg/dl
without insulin. At this time she was still in labor without
nausea or vomiting. Na 144/K 4.0/Cl 112/HCO3 12 with
A/G 20, creat 0.7
Review of glucoses to follow:
(Journal of Perinatology, 2008 (28) 310)
Normoglycemic
DKA in pregnancy
Discussion
Insulin infusion begun with D5 ½ NS at 125 cc/hr,
insulin infusion at 1-2 units/hr. After 8 hrs a/g
normalized, pt underwent C/S for FTP, 3273 gm
infant, 5/9.
Points to remember:
Low insulin – increased hormone sensitive lipase in
adipose – increased FFA release
Low insulin /high glucagon – FFA converted to ketone
bodies in liver
Discussion On L&D, decreased po intake, increased metabolic activity,
facilitated diffusion of glucose across placenta, may yield
normoglycemia:
for prolonged labor or induction, be aware of time
since last po intake and hang D5 as indicated
monitor urine ketones at least q shift - notification re:
ketonuria will help avoid iatrogenic acidemia on busy
labor deck
DKA in Pregnancy- Case Presentation 2
32 yo G3P2002 Japanese woman with prepregnancy
BMI 19.9 and 11 wk 75 gm GTT of 77/137/134
presents at 28 wk ega with fatigue, RBS 348 mg/dl.
BP 110/84, pulse 106/min, temp 36.5 with Kussmaul
respirations and ketotic odor. Lung and cardiac exams
unremarkable. FH 28 cm with no significant abdominal
tenderness. FHT unremarkable.
Lab findings include Na+ 132/K+ 3.8/Cl 98 A/G: 22.
Anti-GAD Ab positive.
Dx’d with DKA, adult onset type 1 DM, treated with
saline, IV insulin and clinical course as noted.
Endo. Diab. Metab. Case Reports 2014
Laboratory Findings on Admission
Discussion
Initial insulin dose 58 units/24 hrs,
decreasing to approx. 10 units/24 hrs
Discharged from hospital at 34 wks,
delivered at 38 wks of healthy infant 3.1
gm, 9/9
Continued insulin postpartum
Discussion Unusual presentation with normal first trimester GTT
Differential diagnosis:
Adult onset type 1 DM
Phenotypic type 2 DM, Ab+
LADA (Latent Autoimmune Diabetes in Adults)
Small fraction of pts with DM2
> age 30
+ for at least 1 Ab (anti-islet cell, anti GAD, anti-insulin)
No insulin Rx for first 6 months of diagnosis
Usually slow progression without DKA or weight loss
Heterogeneous, variable titers of antibodies, BMI and
frequency of progression to insulin dependence
Discussion Screening adult pts with presumed DM2 for DM1 with
Ab:
Age of onset < 50 yrs
Acute symptoms
BMI < 25 kg/m2
Personal or fm hx autoimmune disease
If one or more Ab + (GAD, insulin, tyrosine
phosphatases (IA-2 and IA-2beta), islet cell) –
presumptive DM1, Rx with insulin, avoid oral
hypoglycemic agents
Discussion
DM2 Genetic Defects
MODY mutations
most common form of monogenic DM
2-5% of cases, many misclassified
clinically heterogeneous, defects of insulin secretion
DM2 dx’d at <25 years of age
autosomal dominant
lack of autoantibodies
Discussion
MODY1 – Hepatocyte Nuclear Factor 4A, 10%, Rx
OHA
MODY2 – Glucokinase, 25%, no complications, Rx
diet
MODY3 - Hepatocyte Nuclear Factor 1A,60%, Rx
OHA
Indications for genetic testing:
1) familial DM with autosomal dominant inheritance
2) onset < 25 y.o.
3) non-obese
4) negative islet cell Ab
Points to Remember
DM1 may occur even in setting of normal first trimester glucose
tolerance
Ddx of DM1
LADA – consider Ab testing, review BMI, insulin-dependence
Ddx of DM2
MODY – consider genetic testing
Diseases of exocrine pancreas
Pancreatitis, CF, Hemochromatosis
Endocrinopathies
Cushing’s, Acromegaly Glucagonoma, Pheochromocytoma,
Hyperthyroidism, Somatostatinoma
Drugs
Dilantin, Glucocorticoids, Beta-adrenergic agonists
Genetic syndromes
Turner’s, T21
DKA in Pregnancy- Case Presentation 3
37 yo G4P3003 Saudi woman presents at 33 wks with nausea,
vomiting and diffuse abdominal pain of 48 hrs duration. She
had developed GDM in her 3rd pregnancy and transitioned to
DM2 requiring insulin subsequently
Since unable to take p.o., she omitted her insulin doses. No
fever, UTI or respiratory symptoms.
Bp 120/63, temp 36.8, non-orthostatic. Mild diffuse
abdominal tenderness. FHT category 1
Lab: glucose 75 mg/dl, nl BUN, creat., nl WBC, no left shift.
LFT’s nl; HCO3 10.4/pH 7.32. UA 4+ ketones. A/G 17
Rx: Hydrated with NS
Repeat ABG demonstrated worsening of metabolic acidosis
with pH 7.21, HCO3 7.5
Saudi J. Kidney Dis Transplant 2007 (4) 590
Differential Diagnosis Anion-Gap Acidosis
Ketones
DKA
Alcoholic ketoacidosis A/G=(Na + K)-(Cl + HCO3)
Severe starvation
Metabolic (methylmalonic acidemia)
Lactate
Sepsis/hypoperfusion
Ischemic bowel
Metformin
Exogenous Acids
Methanol
ASA
Ethylene glycol
Reduced renal acid excretion
Chronic renal disease
Discussion
Workup: creat, amylase, lactate nl; salicylate level nl; abd
u/s nl; glucose repeatedly below 200 mg/dl
Pt started on D5 + insulin, dx’d with viral illness, discharged
from hospital 4 days later
Points to remember:
- Ddx anion-gap acidosis
15% of DKA pts present with glucose < 300 mg/dl; more
common in pregnancy
Eating disorders 2x as common in adolescent females with
DM1 compared with nondiabetic peers